A sober look at healthcare after the ACA

The Los Angeles Times leads the way

Chad Terhune’s piece, “Supreme Court’s healthcare ruling: The outlook for California,” offered a clear-eyed look at the repercussions of the Supreme Court’s decision on the healthcare reform law. It presented a realistic assessment of what Obamacare might really mean for California—a blend of the good that the Affordable Care Act does and what it leaves undone for Californians (and residents of other states, too.) His lede:

Amid the cheering in many quarters over the Supreme Court’s decision to uphold the federal healthcare law, a sobering fact remains: Californians ailing healthcare system won’t be easy to fix.

His nut graph:

Millions of Californians will still lack insurance even after a massive coverage expansion. Medical costs and premiums are expected to keep rising, at least in the short run. And many of those who do gain coverage could have a tough time finding a doctor to treat them.

Those challenges have been known in healthcare circles for quite a while and occasionally show up in stories. But Terhune’s piece distilled the problems that remain, post Affordable Care Act, in one crisp graph for readers who want to know what the healthcare law does and does not accomplish.

One of the biggest problems—if not the biggest—is the cost control mess, and Terhune consulted Dr. Arthur Kellerman, a keen observer of the American system who should be high on any health reporter’s source list. Kellerman told Terhune: “The implementation challenges are huge and the expectations for cost control are unrealistic. I’m an ER doctor, and I’ve been reading about the promise of lowering costs by keeping people out of the emergency room for 20 years, and it hasn’t happened yet.” Keeping people out of the ER was one of the selling points for the ACA, but studies have shown that the uninsured are not the major users of emergency rooms. Kellerman, the founding chairman of the department of emergency medicine at Emory University in Atlanta, is the director of RAND Health, a nonprofit research group in Santa Monica.

Terhune also touches on the overuse of medical services, a major reason for medical inflation. He mentions provisions in the ACA that deal with such overuse, but acknowledges that many experts are not sure these ideas will work on a large scale.

Of course, if medical cost inflation continues at a rapid pace, the cost of health insurance most likely will go up, too, causing premium panic for consumers. Terhune placed the premium rise in a historical context for California, where the average premium for employer coverage has increased 154 percent over the last decade. That was more than five times the 29 percent increase in the state’s overall inflation rate. The comparison makes it easy for readers to grasp at a glance the enormity of the problem.

Terhune then reported concern from experts who fear “premiums could rise further as the federal mandate increases demand for health coverage in a market dominated by a small group of insurers.” That’s not an insignificant concern. “Employers are worried the law doesn’t go far enough to reduce the long-term cost trends,” David Lansky, who heads the Pacific Business Group on Health, told the paper.

Terhune does point out the pluses of the Affordable Care Act, reporting that California will receive as much as $15 billion a year to expand its Medi-Cal (Medicaid) program and provide subsidies to the uninsured, who will buy policies in the new state insurance exchange. Some four million Californians are expected to gain coverag.

He also noted a possible countervailing force against medical inflation, reporting that California’s insurance commissioner, Dave Jones, believes that covering even a portion of state residents who are currently uninsured should sharply reduce the amount of uncompensated medical care, which is also driving up the price of health insurance. Hospitals must recoup their losses from uninsured patients who can’t pay, and they do that by shifting those costs to other payers— mostly insurance companies, who in turn build those costs into higher premiums for their policyholders. California families pay on average $1,400 in their annual premiums to cover the medical bills for the uninsured, the paper reported. Jones implies that the cost shifting from payer to payer that’s so prevalent in American healthcare might stop, since more people will have insurance.

But will it? The cost shift question is one to keep an eye on. On his Incidental Economist blog, Austin Frakt noted that “the Supreme Court’s ruling on the Medicaid expansion has made cost shifting from the uninsured a polite dinner topic again.” He goes on to explain how cost-shifting might still occur.

Terhune also notes a longstanding problem—a shortage of primary care physicians, which the ACA could exacerbate, given the number of newly insured people seeking treatment. He knows how to stay on the insurance story, cost shifting, doctor shortage, and all. His strong reporting could lead the way as implementation of the Affordable Care Act rolls along.

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Trudy Lieberman is a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for The Second Opinion, CJR's healthcare desk, which is part of our United States Project on the coverage of politics and policy. She also blogs for Health News Review. Follow her on Twitter @Trudy_Lieberman.
Tags: Affordable Care Act, Healthcare Reform, Medical Inflation, Obamacare

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